Provider Demographics
NPI:1821204637
Name:GRANOFF, CHARLES (LICSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GRANOFF
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-5350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 WASHINGTON ST
Practice Address - Street 2:STE 206
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5520
Practice Address - Country:US
Practice Address - Phone:617-325-2293
Practice Address - Fax:617-325-5618
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10215921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP30141Medicare ID - Type UnspecifiedMEDICARE LEGACY #